STABLE CORONARY ARTERY

DISEASE
Prof. Doina Dimulescu
FESC
Clinica de Cardiologie SUU Elias Bucuresti
Stable Coronary Artery Disease
Epidemiology
Annual incidence 1% for males 45-65 y
Steep increase with age 4% in population of
75-84 y
Decrease in mortality rates although
prevalence did not decrease (improved
prognosis)
Missing data on vasospastic and microvascular
angina (clinical data: 2/3 of stable angina pts
have no coronary stenosis)
Eur Heart J 2013
Diagnostic and Prognostic Evaluation of
the Patient with Suspected SCAD
Step 1: clinical assessment of pre-test probability of
the presence of CAD (PTP)
Step 2: non-invasive testing to establish the presence
of SCAD in patients with intermediate probability
of SCAD
Step 3:optimal medical therapy (OMT) and risk
stratification (usually non-invasive) to select patients
who benefit from invasive investigation and
revascularization
Diagnostic Assessment in SCAD
Traditional Classification of Chest Pain

Eur Heart J 2013

ESC Congress 2013
ESC Congress 2013
Bhatt DL et al JAMA 2006;295:180-189
Clinical Pre-test Probabilities in Patients
With SCAD

Eur Heart J 2013

Classification of Angina Severity according to
Canadian Cardiovascular Society

Eur Heart J 2013

Blood Tests in Assessment of Known or Suspected
SCAD to Optimize Medical Therapy

Eur Heart J 2013

The Ischemic Cascade
Resting ECG for Initial Diagnostic
Assessment of SCAD

Eur Heart J 2013

Echocardiography in SCAD

Eur Heart J 2013

Ambulatory ECG Monitoring for Initial
Diagnostic Assessment in SCAD

Eur Heart J 2013

Investigation in patients with Suspected Coronary
Microvascular Angina

Eur Heart J 2013

Characteristics of Tests Commonly Used to
Diagnose SCAD (and available in Romania)
Dobutamine Echo Stress-testing

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010
SPECT Stress Testing
Inducible Ischemia VS Myocardial Infarction

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010
Coronary MSCT

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010
MRI Stress Testing with Dobutamine

Zamorano J, The ESC Textbook of

Cardiovascular Imaging, Springer 2010
Costs of Cardiac Imaging Procedures
relative to Echo
Sensitivity and specificity of exercise stress test
and immaging stress tests
Exercise ECG for Initial Diagnosis and
Pharmacologic Imaging Stress Tests

Eur Heart J 2013

Coronary MSCT for the Diagnosis of SCAD

Eur Heart J 2013

 The Risk Assessment Strategy

Risk stratification by clinical evaluation

Risk stratification by ventricular function
Risk stratification by response to stress testing
Risk stratification by coronary anatomy

Low event rate annual mortality<1%

Intermediate event rate annual mortality >1% and<3%
High event rate annual mortality >3%
ESC Congress 2013
ESC Congress 2013
Rates of MI and Cardiac Death According to Severity
of Myocardial Perfusion Abnormalities and LVSD
Risk stratification
Definitions for Risk for Various Non-invasiveTest Modalities
Risk Stratification by Coronary Anatomy

Patients with LM severe disease have a poor

prognosis on medical treatment
Three vessel disease and >95% proximal LAD 59%
survival at 5y
Medically treated patients survival at 12y in CASS
Registry
91% normal coronary arteries at invasive angio
74% one vessel disease
59% two vessel disease
50% three vessel disease
Management Based on Risk Determination for
Prognosis in Patients with Suspected SCAD
Nitrates mechanism of action
Beta receptors
Pharmacologic properties of BB
Beta blockers in SCAD
Calcium channel blockers
Dihydropyridine, diltiazem, verapamil
Site of Action of Current and Emerging
Antithrombotic Drugs

Antman E, Cardiovascular Therapeutics ELSEVIER

2013
Statin therapy
ACEIs in SCAD
Beta-blockers post-MI and in SCAD
(REACH Registry)
Revascularization vs optimal medical therapy in
SCAD